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SAN ,,J O A Q U IN Environmental Health Department <br />—COUNTY _...._. <br />Vr iorne�s's haws here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed b APPLICANT <br />Business Name 1 6 R. 0 a/? f4ya Lic. Plate #J6 W 7353 <br />Owner/Operator Name S 1 r;, l/m ES 10/4/0 ZA <br />Business Mailing Address � 735 llBR w z '-41 C T- <br />CitySTDr-KT0d StateLyl Zip 9%520 (6 Bus. Ph4°4)4/1-St93 Alt. Ph. <br />1, S ( L Vt A 15S 171 oZ./} , hereby state that the above information is current, true and correct to <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocationpd penelti , <br />re Z o 2Signatu/ <br />2.- <br />To be completed by <br />, <br />COMMISSARYO�WNER/OPERATOR <br />CommissaryName 1.1111 d IIS C/9TER1nli, //ClAck CEMTEA FA,#1 <br />Address -1717 S. UM54J ST• Bus. Phone �o1Z-? g -Sys 6 <br />CityS�e-kay, C/I Zip 9,6-.10 b j/ , t 7/eOwner/Operator 1Q.o 0 <br />Check all appropriate services provided: <br />p'Wastewater disposal &Y3 -compartment sink Orbectrical hook-ups <br />[!(Solid waste disposal M -Food preparation IZ�'Toilet and handwashing <br />M-'FlOt & Cold water for cleaning 131"Store refrigerated food M Potable water <br />C(Store dry food/supplies ar vernight parking &'Vehicle wash <br />I, fi97- -roW c) , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary own sh rJI notify t e EHD immediately. <br />Signature �i�� Date -1116 4 L J <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />